Sbsq nf care high mdm 45
CPT 99310 covers follow-up visits to patients in nursing facilities or skilled nursing facilities when their condition requires complex medical decision-making. This is for the second and subsequent days of care, not the initial admission.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Document all three MDM elements (problems addressed, data reviewed, risk) to support high complexity
Impact: Prevents downcoding to 99309 ($109.72), protecting $38.75 in revenue per encounter (26% difference)
Explicitly document time spent when using time-based billing (45 minutes typical)
Impact: Time-based billing may be easier to defend on audit than MDM-based; documents total floor/unit time including chart review and care coordination
Bill on the actual date of service, not the date documentation is completed
Impact: Medicare requires billing for the date the face-to-face service occurred; backdating or forward-dating creates compliance risk
Review patient's problem list and medications monthly to ensure all active conditions are addressed
Impact: Comprehensive documentation supports high complexity MDM and reduces audit risk; demonstrates medical necessity for the service level
Coordinate with facility staff to avoid billing 99310 on the same day as another E&M service by a different provider
Impact: Only one E&M service per day is typically reimbursed in nursing facilities unless different specialties and modifier 25 applies
Document any test results reviewed, specialists consulted, or imaging interpreted during the visit
Impact: Data review is a key MDM element; each independent historian, external records reviewed, or test ordered/reviewed adds to complexity score
Common denials
Insufficient documentation to support high complexity medical decision-making
How to appeal: Submit detailed chart notes showing: high-risk problem (e.g., acute illness with systemic symptoms), extensive data review (3+ unique tests or discussion with external provider), and number/complexity of problems managed. Cite 2021/2023 E&M guidelines showing at least 2 of 3 MDM elements meet high complexity threshold.
Frequency limitation - visits appear too routine or not medically necessary
How to appeal: Provide clinical justification for each visit showing changes in patient condition, new problems, or acute exacerbations requiring physician intervention. Include nursing notes or vital signs showing clinical changes that prompted the visit.
Duplicate billing with another provider on same date of service
How to appeal: Demonstrate distinct services by different specialties using modifier 25 and separate documentation, or show the other claim was billed in error and should be withdrawn. Submit specialty credentials and distinct documentation for each provider.
Missing face-to-face documentation or visit appears to be chart review only
How to appeal: Provide documentation explicitly stating face-to-face encounter with patient, physical findings noted, and patient/family counseling provided. Time-stamped nursing facility sign-in logs can support face-to-face contact occurred.
Frequently asked questions
What is the difference between CPT 99310 and 99309?
99310 requires high complexity medical decision-making while 99309 requires only moderate complexity. The 2025 Medicare payment difference is $38.75 ($148.47 for 99310 vs $109.72 for 99309). High complexity requires at least 2 of 3 elements: extensive number/complexity of problems, extensive data review/analysis, or high risk of complications.
How many times per month can I bill CPT 99310?
There is no specific Medicare frequency limit for 99310, but medical necessity must be documented for each visit. Daily billing of 99310 will trigger audits unless clinical documentation supports the frequency and complexity level. Most nursing facility patients receive 1-4 visits per month depending on acuity.
Can nurse practitioners bill CPT 99310?
Yes, nurse practitioners and physician assistants can bill 99310 within their scope of practice and state regulations. In nursing facilities, incident-to billing does not apply, so NPPs bill under their own NPI at 100% of the physician fee schedule rate ($148.47 in 2025).
What RVUs does CPT 99310 have in 2025?
CPT 99310 has 4.59 total RVUs in 2025: 2.8 work RVUs, 1.59 practice expense RVUs (both facility and non-facility), and 0.2 malpractice RVUs. The rates are identical for facility and non-facility settings since nursing facility services are always considered facility settings.
Can I bill 99310 via telemedicine?
Yes, 99310 can be billed via telemedicine using modifier 95 or GT (payer-specific) when conducted via real-time audio and video. CMS has allowed telehealth for nursing facility visits since the COVID-19 pandemic, and many flexibilities have been extended. The reimbursement remains $148.47 when billed with appropriate telehealth modifiers.
How much time is required for CPT 99310?
While 99310 is typically associated with 45 minutes of time, the code is primarily selected based on medical decision-making complexity, not time. However, if using time-based selection, you must document total time spent on the date of service, which includes face-to-face and non-face-to-face time on the facility floor/unit.
What documentation supports high complexity MDM for 99310?
High complexity requires 2 of 3 elements: (1) high number/complexity of problems such as chronic illness with severe exacerbation or acute/chronic illness that poses a threat to life, (2) extensive data review including independent interpretation of tests or discussion with external providers, or (3) high risk of morbidity such as drug therapy requiring intensive monitoring or decision regarding hospitalization.